Prognostic value of histology in patients with non-small cell lung cancer.

To evaluate the impact of non-small cell lung cancer (NSCLC) histological subtypes on survival, we performed a retrospective multivariate analysis of survival in 361 patients with a NSCLC diagnosed in 1987 and 1988 at the University Hospital in Strasbourg, France. There were 262 (73%) squamous cell carcinomas (SQ), 59 (16%) adenocarcinomas other than bronchioloalveolar carcinoma (ADOBAC), 24 (7%) bronchioloalveolar carcinoma (BAC) and 16 (4%) large cell carcinomas (LC). The proportion of metastatic disease was significantly higher in the ADOBAC group than in the SQ group (30% vs. 15%, P < 0.001). In operated patients, only extent of disease and age were independent prognostic factors. In patients with unresectable NSCLC, extent of disease had also the heaviest impact on survival. However, in these unresected patients, ADOBAC had a pejorative impact on survival, in contrast to BAC which was of better prognosis. If these results are confirmed by prospective studies, this will support stratification according to histological subtypes in clinical trials involving inoperable NSCLC patients.

Blood vessel invasion is a major prognostic factor in resected non-small cell lung cancer.

BACKGROUND: We examined the prognostic value of histologic indices in non-small cell lung cancer with particular interest in major blood vessel invasion. METHODS: We studied 593 patients who had curative resection between November 1983 and December 1988. We determined the histology, T and N status, peritumoral lung tissue invasion, tumor stroma, necrosis, mitotic rate, and blood vessel invasion. RESULTS: The median patient survival of the whole series was 3.2 years, with a 5-year survival of 38.9%. In univariate analysis, a high T stage, a high percentage of necrosis, blood vessel invasion, and N stage significantly worsened the survival. In multivariate analysis, only blood vessel invasion and, less significantly, T stage and lymph node metastasis remained independent prognostic factors. CONCLUSIONS: These results highlight the negative prognostic value of blood vessel invasion in non-small cell lung cancer and suggest that blood vessel invasion, T stage, and node metastasis are three unrelated and distinctive characteristics of resected non-small cell lung cancer.

Pneumonectomy for chronic infection is a high-risk procedure.

BACKGROUND: The purpose of this study was to estimate operative risk, and to identify indicators of adverse prognosis, in patients undergoing pneumonectomy for chronic infection. METHODS: Twenty-five patients aged 41 +/- 15 years underwent pneumonectomy (three completions) for chronic infection: sequelae of tuberculosis, 15; cystic bronchiectasis, 9; and radiation pneumonitis, 1. Eight patients had aspergilloma (7 after tuberculosis, 1 with radiation pneumonitis). RESULTS: Operative mortality was 4%. Operative blood loss was estimated at 1,983 +/- 1,424 mL, ranging from 150 to 5,600 mL. A single patient required reexploration. Eight patients (32%) had empyema, and a further 3 (12%) had bronchopleural fistula; thoracoplasty was required for 10 (40%). Sequelae of tuberculosis heralded increased operative bleeding (t = 2.884; p < 0.005). Incidence of empyema or bronchopleural fistula was increased in patients with sequelae of tuberculosis (chi 2 = 3.896; p < 0.05), patients with aspergilloma (chi 2 = 4.588; p < 0.05), patients in whom the parenchymal cavities were entered (chi 2 = 11.5; p < 0.001), and those in whom blood loss was in excess of 1,000 mL (chi 2 = 4.911; p < 0.05). CONCLUSIONS: We conclude that pneumonectomy is a high-risk procedure, especially in patients with sequelae of tuberculosis.

Tracheobronchial lacerations after intubation and tracheostomy.

BACKGROUND: Although long-term complications of intubation and tracheostomy are well documented, little has been reported on acute complications of airway access techniques. METHODS: Fourteen patients (1 male and 13 female patients) aged 15 to 80 years presented with tracheobronchial lacerations after single-lumen intubation (n = 9), double-lumen intubation (n = 1), or tracheostomy (n = 4). RESULTS: A left bronchial laceration after double-lumen intubation was discovered and repaired intraoperatively. A tracheal laceration after single-lumen intubation was recognized during induction of anesthesia. The remaining 12 were diagnosed within 6 to 126 hours (median, 24 hours) after injury. All patients had mediastinal and subcutaneous emphysema. At endoscopy, 12 injuries were located in the thoracic trachea and 1 in the cervical trachea. Twelve underwent primary repair through a right thoracotomy (n = 11) or left cervicotomy (n = 1), and 1 was treated conservatively. Two patients with tracheostomy injury died postoperatively. All repairs healed well but one. The latter was performed 5 days after the injury; a dehiscence occurred, but healed spontaneously. CONCLUSIONS: We conclude that prognosis of tracheal lacerations depends both on the general health of the patient and on the rapidity of diagnosis and treatment.

Bronchogenic cancer in the elderly: operative risk and long-term prognosis.

Surgery for bronchogenic cancer raises the question of benefit to elderly patients. The present study reviews a cohort of 223 patients aged 70 years and more (range: 70-84), who underwent thoracotomy for pulmonary malignancy over a 10-year period. The aim of the study was to evaluate both operative risk and 5-year survival. Medical history was negative in 29% of the patients; 26% had a history of cardio-vascular disease, and 19% had a history of malignancy in complete remission. Tumor histology was squamous-cell carcinoma for 70.4%, adenocarcinoma for 24.2%, large-cell carcinoma for 3.6%, and small-cell carcinoma for 1.3% of the patients. 48.4% of patients were in stage I, 17.2% in stage II, and 30.3% in stage III. Exploratory thoracotomy was carried out in 5.8% of patients. A resection was achieved in 210 patients (pneumonectomy in 28.5%, lobectomy in 71.5%). Operative mortality was 7.2% for the whole series, 10% after pneumonectomy and 6.6% after lobectomy. Mortality was similar below and above 75 years. Overall 5-year survival was 32.9% (45.7% for stage I, 36.3% for stage II, and 13.8% for stage III). Survival was not influenced by age, symptomatic or asymptomatic presentation, medical history, and in particular not by history of malignant disease. Although operative mortality is slightly increased when compared to younger patients, long-term results legitimize surgery for bronchogenic cancer in the elderly.

Association of bronchial and pharyngo-laryngeal malignancies. A reappraisal.

OBJECTIVE: The purpose of this study was to re-evaluate operative risk and probability for survival patients with a history of upper aerodigestive cancer, who underwent thoracotomy for presumed primary bronchogenic cancer. Our hypothesis was to consider any isolated lung opacity as a primary bronchogenic cancer. METHODS: The cohort under investigation included 114 consecutive patients. Histology of bronchial cancer was squamous cell carcinoma in 98 patients (86%), adenocarcinoma in 14 (12%) and large cell carcinoma in 2 (2%). Exploratory thoracotomy was performed in 5 patients (4%); the remaining 109 patients underwent a potentially curative resection, including 25 pneumonectomies (22%) and 84 conservative resections (74%). Pathological staging was as follows: 66 stage I (58%), 20 II (17.5%), 20 IIIa (17.5%), 6 stage IIIb (5%), and 2 stage IV (2%). RESULTS: Four patients died post-operatively (3.5%). Non-fatal morbidity concerned 32 patients (28.1%) and was dominated by respiratory superinfections. Incidence of respiratory infections was increased after voice-sparing resections (chi 2 = 4.311, P < 0.05), and more particularly after transmaxillary buccopharyngectomy (chi 2 = 12.224; P < 0.01). Estimated 5-year survival was 28.7% (33.3% in stage I, 19.2% in stage II, and 30.2% in stage III). There was no difference in survival with reference to the location of head and neck cancer (chi 2 = 3.412; 0.05 < P < 0.1) or chronology (chi 2 = 0.005; P > 0.9). CONCLUSIONS: We conclude that isolated lung opacities in patients with previous or simultaneous head and neck cancer are most likely primary bronchogenic cancers. The acceptable operative mortality legitimizes surgical treatment despite an impaired 5-year survival; patients with a previous voice-sparing operation are at increased risk for respiratory complications and should be managed carefully.

Decortication is a valuable option for late empyema after collapse therapy.

BACKGROUND: Infection of previous collapse therapy spaces may raise challenging problems. This study evaluated a conservative surgical approach based on decortication. METHODS: Since 1979, 28 patients (mean age, 60 +/- 6 years) have presented at an average of 37 +/- 7 years after artificial pneumothorax for tuberculosis. Diagnosis of empyema was made on follow-up in 12 patients and on symptoms in 16 patients. Mean vital capacity was 66% +/- 16% of normal. Microorganisms were isolated in 13 patients (Aspergillus fumigatus in 5, Mycobacterium tuberculosis in 4, anaerobes in 4). Decortication was made in 24 patients, associated with thoracoplasty in 4, and with partial lung resection in 2 patients. Thoracoplasty alone was performed in 2 patients, and 2 patients underwent an extrapleural pneumonectomy. RESULTS: Both extrapleural pneumonectomies were complicated with empyema requiring thoracoplasty, resulting in one postoperative death. Operative mortality after decortication was nil. Mean intraoperative blood loss during decortication was 1,830 +/- 1,310 mL. All patients were extubated within 24 hours, except 1 patient who was ventilator-dependent preoperatively. Prolonged air leaks were common (mean duration of drainage, 16 +/- 11 days), but ultimately sealed. Existence of symptoms was predictive of prolonged air leaks (p < 0.01). CONCLUSIONS: We conclude that decortication may provide a one-stage cure avoiding the hazards of extrapleural pneumonectomy; the nonfunctioning remaining lung may resolve the space problem.

Are bilobectomies acceptable procedures?

BACKGROUND: Controversy about operative morbidity and oncologic value of bilobectomy has led to a review of our experience over the past 12 years. METHODS: The charts of 112 patients (100 men and 12 women with a mean age of 63 years) were reviewed for operative mortality and morbidity and long-term survival. Survival of patients with stage I or stage II disease was compared with that of stage-matched and age-matched groups having right pneumonectomy. RESULTS: Four patients (3.5%) died postoperatively. Nonfatal complications occurred in 55 patients (49%); the most frequent problem was pleural space disease (34%). Survival studies focused on the 96 patients with nonsmall cell bronchogenic cancer (44 in stage I, 32 in stage II, and 20 in stage IIIA). The overall 5-year survival rate was 40%; the 5-year survival rate was similar for stage I and stage II (41% for stage I, 50% for stage II, and 17% for stage IIIA). The incidence of local recurrence was significantly increased after bilobectomy for stage I cancer (chi 2 = 5.066; p < 0.05) compared with pneumonectomy but did not affect 5-year survival. Local recurrence and survival were similar after bilobectomy and pneumonectomy in stage II. CONCLUSIONS: These data demonstrate an increased morbidity after bilobectomy. Survival studies demonstrate an increased risk of local recurrence in patients with stage I disease, which might be partly explained by understaging.

[Surgical treatment of pneumothorax. Study of a series of 400 cases]. / Traitement chirurgical du pneumothorax. Etude d'une série de 400 cas.

Surgical management is indicated for recurrent forms of pneumothorax as well as for failures of tube drainage. We report a series of 400 patients treated surgically mainly by pleural abrasion over the past 17 years. Statistical analysis of the results identifies two groups: 308 patients under the age of 45 years had surgery mainly for spontaneous idiopathic pneumothorax, where as 92 patients over the age of 45 years had surgery mainly for emphysema. In young patients, the axillary incision was preferred due to the lack of muscular sequelae and to avoid unpleasant aesthetic sequelae. Postoperative complications occurred in 60 patients (15%). The main complication was a residual pneumothorax after drain removal requiring further drainage (10%). A single recurrence occurred (0.25%). Pleural abrasion is a very effective way to treat recurrent forms of pneumothorax.

Early and long-term results after completion pneumonectomy.

From January 1, 1978 to December 31, 1992, 37 patients underwent a completion pneumonectomy after a previous lobectomy (36 men and 1 woman; mean age, 60 years; range, 41 to 77 years). These account for 4.8% of 758 pneumonectomies. The purpose of the present study was to evaluate the operative results of completion pneumonectomy and long-term survival in patients with bronchogenic cancer. The initial lung resection had been performed for primary bronchogenic cancer in 23, metastatic thyroid adenocarcinoma in 1, and benign diseases in 13 (tuberculosis in 11, aspergilloma in 1, and bronchiectasis in 1). Completion pneumonectomy was required for bronchogenic cancer in 32 (15 stage I, 6 stage II, 11 stage III). One patient had relapsing metastatic thyroid carcinoma, 2 had bronchiectasis, and 2 had a venous infarction after lobectomy. Four patients (10.8%) died perioperatively of the following causes: 1 fatal intraoperative bleeding, 1 fatal postoperative bleeding, 1 pneumonia, and 1 malignant hypercalcemia. Median operative blood loss was 1,000 mL, and 19 patients experienced bleeding exceeding 1,000 mL (51%). Six patients had intraoperative vascular injury. Nonfatal surgical complications occurred in 9 patients (24%), including 5 clotted hemothoraces, 3 empyemas, and 1 bronchopleural fistula. Four patients had medical complications (2 pulmonary edemas, 1 sinus tachycardia, and 1 unexplained fever). Twenty-three had an uneventful straightforward recovery (62%).(ABSTRACT TRUNCATED AT 250 WORDS)

Respiratory complications after surgical treatment of esophageal cancer. A study of 309 patients according to the type of resection.

This study analyzes the respiratory complications in a retrospective study of 309 resections for esophageal cancer. We mainly performed two types of resections according to the height of the tumor: the Ivor-Lewis resection for middle thoracic lesions (182 cases), and the Akiyama resection for upper thoracic lesions (127 cases). We compared the respiratory complications occurring after these two procedures. Our overall mortality and morbidity rates were, respectively, 9% and 37%. In our series, the mortality rate was 4 times higher after the Akiyama procedure than after the Ivor-Lewis procedure, and the morbidity was twice as high. Respiratory complications accounted for 64% of the postoperative deaths. The Akiyama procedure yielded more respiratory complications, especially isolated bronchopneumonia and necrosis of the trachea or of the right or left main bronchus. Respiratory complications accounted for 53% of morbidity, mainly recurrent nerve paralysis with false passages and stasis in the transplant. Both are directly related to the surgical act and often result in bronchopneumonia. Rather than the surgical technique or the skill of the surgeon, it seems that local factors, such as the position of the tumor on the esophagus, increased the incidence of recurrent nerve paralysis following the Akiyama procedure. However, the rate of respiratory complications remained high after the Ivor-Lewis procedure. Patient history, which sometimes included a previous ENT cancer, must be taken into account, as well as the gravity of the operation and the duration of the intubation. Frequent false passages and reflux must be fought by intensive physiotherapy and, when necessary, by early tracheotomy before the patient develops postoperative acute respiratory distress syndrome.

[Results of repeated pulmonary resection in new homolateral neoplastic localization after conservative resection]. / Résultats de la chirurgie d'exérèse pulmonaire itérative pour nouvelle localisation néoplasique homolatérale après exérèse conservatrice.

From 1978 through 1992, 93 patients with a previous lobectomy for bronchogenic cancer were referred for homolateral cancer recurrence. Forty-six patients were contraindicated for carcinologic reasons (30 stage IIIb and 16 stage IV). Forty-seven patients (50.5%) were resectable, but 17 did not undergo surgery for associated medical problems (n = 11) or refusal (n = 6). The remaining 30 patients form the population of the present study: 29 males and 1 female; mean age of 61 years (range 47-72). The previous cancer was stage I in 26 and stage II in 4. The mean interval between the 2 cancer diagnoses was 30 months (range 6-97). Three patients underwent an exploratory thoracotomy (10%): 2 had mediastinal involvement and 1 had pleural metastases. Twenty-two (73%) underwent a completion pneumonectomy, and 5 had miscellaneous conservative resections. There were 4 operative deaths (13%): one intraoperative bleeding, 1 postoperative bleeding, 1 pulmonary embolism, 1 pneumonia. Four patients had nonfatal surgical complications: 2 clottings (reexploration), 1 empyema (lavage) and 1 bronchopleural fistula (thoracoplasty). Resected patients were staged as follows: 13 stage I, 4 stage II, 10 stage III. Survival following resection including operative mortality at 3 an 5 years was estimated as 52.5% and 44% for the whole series (72% for stage I). We conclude that repeat surgery conveys an increased risk, but may achieve valuable long-term results.

Can we predict very short term survival in small cell lung cancer?

We retrospectively reviewed the charts of 151 consecutive patients diagnosed as small cell lung cancer in our department and who had at least one course of chemotherapy. Nineteen patients died during the first 2 months, of the probability were reported to construct a receiver operating characteristic curve i.e. 13% of the population. The probability of dying within 2 months was investigated through a stepwise logistic regression. A performance status < or = 70 (Karnofsky index), an age > 60, a platelet count < or = 150,000/mm3, elevated alkaline phosphatase and a sodium < or = 135 mmol/l were independent predictors of a very short term survival and contributed to the equation for the probability of dying within a 2-month period. Sensitivity and specificity for various cutoff points characteristic curve allowing one to determine for a given patient his risk of being a very short term survivor. Such an approach could prevent inclusion of patients with high risk of early death in clinical trials and help to choose appropriate treatments for such poor risk patients.

Bronchogenic cancer associated with head and neck tumors. Survival analysis of 194 patients.

We reviewed a series of 194 lung opacities presumed to be bronchogenic carcinomas occurring either simultaneously with (n = 46) or metachronously to (n = 148) a head and neck cancer. The purpose of the study was to evaluate the operative mortality and morbidity and to assess with a survival analysis whether the lung lesions actually were primary carcinomas or metastases of the head and neck cancer. Operation was contraindicated in 77 patients: 36 for metastatic spread, 5 for small-cell carcinoma, and 35 for respiratory insufficiency. The remaining 118 underwent operation: lobectomy for 82, pneumonectomy for 30, wedge resection for 1, and exploratory thoracotomy for 5. The operative mortality was 5%, and the nonfatal morbidity was 22%. The survival at 5 years for patients who underwent operation for bronchogenic cancer was 19.7% (27.2% for stage I, 19% for stage II, 4.5% for stage IIIA, and 0% for stage IIIB). The survival of these patients was not significantly different with respect to the synchronous or metachronous occurrence or the histologic classification (squamous or non-squamous). We conclude that, despite the poor survival, several of these lung lesions associated with a head and neck cancer were most likely a primary bronchogenic cancer. Surgical management is justified because of the observed postoperative mortality.

[Result of surgery of esophageal cancer. Analysis of a series of 349 cases based on resection methods]. / Résultat de la chirurgie du cancer de l'oesophage. Analyse d'une série de 349 cas selon les types d'exérèse.

Despite obvious improvements in operative and postoperative management after esophageal resection, surgical treatment of esophageal cancer is still disappointing in terms of long term results. The purpose of the present study was to verify these poor results statistically and to discuss the value of a modified therapeutic approach. Our experience covers 349 esophageal resections performed between 1979 and 1992. These patients were predominantly males (93%) with squamous cell carcinoma (86%). The majority of the patients underwent either an Ivor-Lewis (52%) or an Akiyama procedure (36%). Survival was estimated according to the Kaplan-Meier model. Influence of parameters such as sex, histology, type of resection and TNM-staging was assessed with the "log-rank" test. The perioperative mortality was 10%. The non-fatal morbidity rate was 34%, and was most often related to anastomotic leaks. Pathological staging disclosed a majority of T3 tumors (71%). The overall survival rate was 54% at one year, 28% at 2 years and 9% at 5 years. This survival was not influenced by either histology (squamous cell or adenocarcinoma), the type of resection (Ivor-Lewis or Akiyama procedure). A slightly superior survival rate was observed after Ivor-Lewis procedure and is explained by a lower postoperative complication rate. In particular, diffuse N2 disease (abdominal and mediastinal) had a worse prognosis than localized N2. N1 disease was probably understaged, since survival was comparable to localized N2. The natural history was characterized by development of metastases (43%) rather than by local recurrence. We conclude that these results may justify surgery for palliation of dysphagia in so far as the post-operative morbidity is reduced, as we observed with Ivor-Lewis procedures. However, improvement of long-term survival requires a multimodality oncologic approach.

[Surgical treatment of pulmonary and bronchial aspergilloma]. / Traitement chirurgical de l'aspergillome pulmonaire et bronchique.

From 1974 to 1990, 61 patients were admitted for pulmonary (55) or bronchial (6) aspergilloma; 50 were treated by surgery. Operative treatment was mandatory because of disabling symptoms in 17 patients, rapid growth on radiological survey in 7 others, diagnostic doubt in 10 and association with bronchogenic cancer in 2. 14 were operated on in order to prevent evolutive complications. Complete resection was possible in 39 patients: with lobectomy or segmentectomy in 34 and with pleuro-pneumonectomy in 5. In 10 others, respiratory failure only allowed speleotomy and thoracoplasty. One thoracotomy was exploratory because of an associated unresectable cancer. Postoperative complications frequently occurred with pulmonary aspergilloma: 4 postoperative deaths, 33 experienced non-fatal complications (28 major bleedings, 16 rehabititation defects, 6 empyemas, 5 respiratory failures). Nevertheless, among 10 patients with either bronchial aspergilloma or pulmonary aspergilloma without underlying disease, only one had a complicated outcome. In conclusion, surgical treatment is well tolerated in the absence of underlying parenchymal disease. However, despite the major operative risk, surgery remains the only efficient treatment in symptomatic patients.

[Pre-therapeutic prognostic factors of survival in small cell bronchial cancer. Retrospective study in a series of 112 patients]. / Facteurs pronostiques préthérapeutiques de la survie dans le cancer bronchique à petites cellules. Etude rétrospective d'une série de 112 patients.

Pretherapeutic prognostic factors were studied retrospectively in 112 consecutive patients diagnosed as small cell lung cancer between January 1st 1986 and December 30th 1990 in our department. Mean age of the population was 59.3, 89.3% were males. Median survival time of the whole population is 11.66 months. It is 15.3 months for the 48 patients with limited disease stage and 9.74 months for 64 patients with extensive disease stage. Among the patients with limited disease stage, those with supraclavicular lymph nodes had a significantly shorter survival (p < 0.001). Univariate analysis of survival identified age, performances status, weight loss, T, N, bone and liver involvement, serum sodium, albumin and sedimentation rate as prognostic factors. The final model in multivariate analysis of survival includes for the patients with performance status < or = 70, extent of disease as an independent prognostic factor and for the patients with performance status < 70, extent of disease, serum sodium and albumin.

Pleuropulmonary aspergilloma: clinical spectrum and results of surgical treatment.

From 1974 to 1991, 77 patients were admitted for pulmonary (55), pleural (16), or bronchial (6) aspergilloma. About 50% were asymptomatic. Sixty-three underwent operation. Pulmonary aspergillomas were operated on for therapeutic need in 26 and on principle in 18; the procedures were 28 lobar or segmental resections, 10 thoracoplasties, and 5 pleuropneumonectomies (1 patient had exploration only). Pleural aspergillosis was treated by operation on principle in 5 and for therapeutic need in 8 patients; 10 thoracoplasties, 1 attempt at pleuropneumonectomy, and 2 decortications were performed. All six bronchial lesions were operated on as a rule. Overall postoperative mortality was 9.5%. Major complications were bleeding (n = 37), pleural space problems (n = 24), respiratory failure (n = 6), and postpneumonectomy empyema (n = 4). All patients with pleural disease experienced complications. The outcome was better after lobar or segmental resection than after thoracoplasty (mortality, 6% versus 15%). Asymptomatic and nonsequellary pulmonary or bronchial aspergilloma also had an improved outcome. We conclude that operation is at low risk in pulmonary or bronchial locations in asymptomatic patients and in the absence of sequellae; the risk is high in symptomatic patients for whom operation is the only definite treatment. Pleuropneumonectomy should be avoided. Only symptomatic pleural aspergilloma should be operated on.

[Iatrogenic tracheobronchial lesions during intubation. 5 cases and review of the literature]. / Plaies trachéobronchiques iatrogènes au cours de l'intubation. 5 observations et revue de la littérature.

The authors report about a personal series of 5 cases of tracheal injuries during intubation. One lesion was caused by a Carlens' tube and it was discovered and repaired during thoracotomy. Four wounds resulted from the use of ordinary tubes. Three of them affected only the tracheal membrane. The diagnosis was established with fiberendoscopy after subcutaneous emphysema occurred while the patient was awakening. Two patients underwent surgical repair, and a watch-and-wait policy was applied for another one. The outcome was favorable for these 4 patients. The last patient had a tracheoesophageal wound in a context of irradiated cervical neoplastic recurrence. The diagnosis was suggested by the discovery of major ampents of air in the small bowel during laparotomy for jejunostomy. The outcome was fatal. These cases have been compared with a compilation of the literature, gathering 8 wounds caused by ordinary tubes and 25 caused by Carlens-type tubes.